Integrated Biological and Behavioral Surveillance Survey among Male Labor Migrants in 11 Districts in Western and Mid to Far Western Regions of Nepal

Transcription

1 Integrated Biological and Behavioral Surveillance Survey among Male Labor Migrants in 11 Districts in Western and Mid to Far Western Regions of Nepal Round II ASHA Project Family Health International /Nepal Baluwatar P.O. Box 8803 Kathmandu, Nepal January 2009

2 In July 2011, FHI became FHI 360. FHI 360 is a nonprofit human development organization dedicated to improving lives in lasting ways by advancing integrated, locally driven solutions. Our staff includes experts in health, education, nutrition, environment, economic development, civil society, gender, youth, research and technology creating a unique mix of capabilities to address today s interrelated development challenges. FHI 360 serves more than 60 countries, all 50 U.S. states and all U.S. territories. Visit us at

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4 Submitted to: Family Health International/Nepal Gopal Bhawan, Anamika Galli P.O. Box 8803 Kathmandu, NEPAL Submitted by: New ERA P.O. Box 722 Rudramati Marga, Kalopul Kathmandu, Nepal In Collaboration with STD/AIDS Counselling and Training Services P.O. Box 7314 Pyukha, Kathmandu, Nepal January 2009 Family Health International/Nepal USAID Cooperative Agreement #367-A Strategic Objective No. 9 iii

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6 ACKNOWLEDGEMENTS This survey was conducted within the IBBS series under the HIV/AIDS Surveillance Plan. We would like to express our sincere gratitude to Family Health International/Nepal (FHI/Nepal) for entrusting us with the responsibility of conducting the survey. Our deep appreciation goes to Ms. Jacqueline McPherson, Country Director, FHI/Nepal and Mr. Satish Raj Pandey, Deputy Director, FHI/Nepal. Their input throughout the course of this study has proved invaluable. Special thanks go to Dr. Laxmi Bilas Acharya, Team Leader - Surveillance and Research, FHI/Nepal, for his technical input and guidance throughout. Furthermore, the study team would like to thank the Primary Health Center of Syangja, the Nepal Family Planning Association of Kapilvastu, the Social Awareness and Development Campaign Nepal of Gulmi, the Nepal Red Cross Society of Kanchanpur, the District Health Office of Kanchanpur, the Community Development Forum of Doti, Digo Bikash of Surkhet, and N-SARK of Banke district for providing counselors for post-test counseling service and test result dissemination to the study participants. We are also indebted to various organizations from the Mid to Far Western region. for their valuable suggestions and contributions throughout the study period: Nawakiran Plus (Achham, Doti, Surkhet ); the Nepal Red Cross Society (Kailali, Surkhet, Doti, Kanchanpur); the Oppressed Class and Women s Awareness Center, Gongotri; Sneha Samaj, Hasti AIDS, the National Health Foundation (Achham); Samaj Sewa, the Community Development Forum and Deep Joyti Samaj Kendra (Doti); the National Nepal Social Welfare Association, Nava Asha (Kanchanpur); VCT of Nepal STD and AIDS Research Center (Kailali); Digo Bikash Kosh, the Social Awareness Center (Surkhet); and Nagarjun Development Committee, Safe Nepal, Nepal STD and AIDS Research Center (Banke). Likewise, we are also grateful to various organizations of the Western region, and thank the Nepal Family Planning Association (Kapilvastu); the National Rural and Community Development Center Nepal, Social Awareness and Development Campaign Nepal (Gulmi); the Nepal Red Cross Society (Gulmi, Syangja and Kaski); and the Primary Health Center (Syangja) for their valuable suggestions and contributions throughout the study period. We would like to gratefully acknowledge the Nepal Police, the National Center for AIDS and STD Control (NCASC), the District Aids Coordination Committee (DACC), the District Public Health Office (DPHO) and the Chief District Officer (CDO) in the study districts for providing the necessary administrative support during the study period. Finally, special appreciation goes to our respondents who, despite their busy lives, gave us valuable time for the interview and shared their personal experiences. - New ERA Study Team i

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8 STUDY TEAM MEMBERS Key Team Members 1. Mr. Sidhartha Man Tuladhar - Project Director 2. Mr. Niranjan Dhungel - Project Co-ordinator 3. Mr. Sunil Acharya - Associate Research Officer 4. Ms. Pranita Thapa - Research Officer 5. Mr. Ramesh Dangi - Senior Research Assistant 6. Mr. Sachin Shrestha - Senior Research Assistant 7. Mr. Laxmi Datta Sapkota - Senior Counselor 8. Ms. Sarmila Prasai - Senior Computer Programmer Field Study Team Members 1. Mr. Rabindra Udash - Field Research Assistant 2. Mr. Kripa Acharya - Field Research Assistant 3. Mr. Yubaraj Dahal - Field Research Assistant 4. Mr. Mahesh Prasad Deo - Field Research Assistant 5. Mr. Manoj Bhattarai - Field Research Assistant 6. Mr. Megh Bahadur Khatri - Field Research Assistant 7. Mr. Surendra Kumar Mahato - Field Supervisor 8. Mr. Bishnu Rijal - Field Supervisor 9. Mr. Gajendra Bahadur Karki - Field Supervisor 10. Mr. Pom Narayan Panthi - Field Supervisor 11. Mr. Sabin Karki - Field Supervisor 12. Mr. Dev Bahadur Dangi - Field Supervisor 13. Mr. Rajendra Acharya - Field Supervisor 14. Mr. Ram Prasad Khanal - Field Supervisor 15. Mr. Dhurba Raj Thapa - Field Supervisor 16. Mr. Anil Bhattarai - Field Supervisor 17. Mr. Khadananda Mainali - Field Supervisor 18. Mr. Nawa Raj Thapa - Field Supervisor 19. Mr. Gopal Regmi - Field Supervisor 20. Mr. Jyoti Gurung - Field Supervisor 21. Mr. Dilip Joshi - Field Supervisor 22. Mr. Ganga Bahadur Basnet - Field Supervisor 23. Mr. Ishwor Acharya - Field Supervisor 24. Mr. Lekh Nath Mainali - Field Supervisor 25. Mr. Dambar Prasad Upadhya - Field Supervisor 26. Mr. Rajendra Bhatta - Field Supervisor 27. Mr. Tanka Prasad Bimali - Field Supervisor 28. Mr. Rajendra Singh - Field Supervisor 29. Mr. Keshar Dhakal - Field Supervisor 30. Mr. Shankar Datt Joshi - Field Supervisor 31. Mr. Lalan Prasad Shah - Sr. Health Assistant 32. Mr. Dipendra Kumar Yadav - Health Assistant 33. Mr. Prabin Shrestha - Health Assistant ii

9 34. Mr. Rajendra Phaiju - Health Assistant 35. Mr. Mukti Prasad Dahal - Health Assistant 36. Mr. Shanjaya Shah - Health Assistant 37. Mr. Khimananda Rijal - Counselor 38. Mr. Laxmi Pandey - Counselor 39. Mr. Lalmani Bhandari - Counselor 40. Mr. Kamal Pandey - Councelor 41. Mr. Bikash Pokharel - Councelor 42. Mr. Santosh Pathak - Councelor 43. Mr. Lal Bahadur Dhami - Councelor 44. Mr. Mukunda Singh - Councelor 45. Mr. Deepak Kumar Chand - Councelor 46. Mr. Pratap Singh Nayak - Councelor 47. Mr. Prakash Bhatta - Councelor Data Entry/Tabulation /Coding 1. Ms. Deepa Shakya - Coder 2. Ms. Mamata K.C. - Coder 3. Ms. Ishwori Rijal - Coder 4. Ms. Saraswoti Bista - Coder 5. Ms. Sharada Dangol - Coder 6. Mr. Babu Raja Dangol - Coder 7. Mr. Himal Awosthi - Coder 8. Mr. Birochan Upreti - Coder 9. Mr. Gehendra Pradhan - Data Entry Person 10. Mr. Prabhat Pradhan - Data Entry Person 11. Ms. Sanu Maiya Shrestha - Data Entry Person 12. Ms. Dejeena Amatya - Data Entry Person Administration Support 1. Mr. Sanu Raja Shakya - Senior Word Processor 2. Ms. Geeta Shrestha (Amatya) Senior Word Processor 3. Mr. Rajendra Kumar Shrestha - Office Assistant Laboratory Team (SACTS) 1. Dr. Vijaya Lal Gurubacharya - Consultant Pathologist 2. Mr. Janardan Kuinkel - Senior Lab Technician 3. Mr. Binod Shrestha - Lab Technician 4. Mr. Narahari Poudel - Lab Technician 5. Mr. Rajan Rajthala - Lab Technician 6. Mr. Sunil Kumar Shah - Lab Technician 7. Mr. Ukesh Shrestha - Lab Technician 8. Mr. Gajendra Chaudhary - Lab Technician iii

10 TABLE OF CONTENTS iv Page ACKNOWLEDGEMENTS...i STUDY TEAM MEMBERS...ii TABLE OF CONTENTS...iv LIST OF TABLES...vi LIST OF FIGURES... viii ABBREVIATIONS...ix EXECUTIVE SUMMARY...xi CHAPTER - I: INTRODUCTION Context Objective of the Study...2 CHAPTER - II: METHODOLOGY Study Population Study Area Sample Design and Sample Size Preparation for Fieldwork Implementation of the Study Field Operation Procedures Coordination and Monitoring Ethical Issues HIV/STI Pre- and Post-test Counseling and Follow-Up Constraints in the Field Work...8 CHAPTER - III: KEY FINDINGS Birth Place and Current Living Place Socio-demographic Characteristics Migration History of the Respondents Sexual Behavior Sexual Practices of Male Labor Migrants in Nepal Sexual Contact with Female Sex Workers in Nepal Condom Use with Female Sex Workers in Nepal Sexual Contact with Spouse and Condom Use Sexual Contact with Girlfriends and Condom Use in Nepal Sexual Contact with Other Female Partners in Nepal and Condom Use Sexual Practices of Male Labor Migrants in India Sexual Contact with Female Sex Workers in India Sexual Contact with Girlfriends and Condom Use in India Sexual Contact with Other Female Partners and Condom Use in India Availability of Condoms Knowledge of HIV/AIDS Access to HIV/AIDS Awareness Messages Knowledge and Treatment of Sexually Transmitted Infections (STIs) Perception on HIV Test Use of Alcohol and Drugs...30

11 3.14 Knowledge of HIV/AIDS Stigma and Discrimination...33 CHAPTER - IV: HIV PREVALENCE Prevalence of HIV Relationship between Socio-Demographic Characteristics and HIV Infection...34 CHAPTER - V: EXPOSURE TO HIV/AIDS/STI PROGRAMS...36 CHAPTER - VI: COMPARATIVE ANALYSIS OF 2006 AND 2008 IBBS RESULTS Socio-demographic Characteristics Migration History Sexual Experience Sexual Behavior Prevalence of STI Symptoms Proper Knowledge on Protection from HIV Infection HIV Prevalence...43 CHAPTER - VII: CONCLUSIONS AND RECOMMENDATIONS Conclusions Recommendations...51 ANNEXES v

12 LIST OF TABLES Page Table 3.1: Number of Respondent by Birth District...9 Table 3.2: Socio-demographic Characteristics of Respondents...10 Table 3.3: Migration Destinations of Male Labor Migrants...12 Table 3.4: Male Labor Migrants by Migration Characteristics...13 Table 3.5: Types of Work of Male Labor Migrants in India...14 Table 3.6: Districts Visited and Types of Work Performed by Returnee Migrants in Nepal...15 Table 3.7: Sexual Behavior of Male Labor Migrants...16 Table 3.8: Sexual Behavior of Male Labor Migrants with FSWs in Nepal...17 Table 3.9: Sexual Behavior of Male Labor Migrants and Condom Use by Them with their Spouses in Nepal...18 Table 3.10: Sexual Behavior of Male Labor Migrants and Condom Use by them with Girl Friends in Nepal...19 Table 3.11: Sexual Behavior of Male Labor Migrants and Condom Use with Other Female Partners in Nepal...20 Table 3.12: Sexual Behavior of Male Labor Migrants with FSWs in India...21 Table 3.13: Sexual Behavior of Male Labor Migrants and Condom Use by them with FSW in India...21 Table 3.14: Availability of Condoms as Reported by Male Labor Migrants...24 Table 3.15: Other Sources of Knowledge of HIV/AIDS among Male Labor Migrants...25 Table 3.16: Knowledge of HIV/AIDS among Male Labor Migrants...26 Table 3.17: Understanding of STIs and Reported STI Symptoms (Past Year)...27 Table 3.18: Reported Treatment of STI among Male Labor Migrants (Past Year)...28 Table 3.19: Reported STI Treatment among Male Labor Migrants (Current)...29 Table 3.20: Knowledge about HIV Testing Facilities among Labor Migrants and History of HIV Test...30 Table 3.21: Use of Alcohol and Drugs among Male Labor Migrants...31 Table 3.22: Knowledge on HIV Infection among People they Know, and Knowledge of Ways of HIV/AIDS Transmission among Male Labor Migrants...32 Table 3.23: Stigma Against HIV/AIDS among Male Labor Migrants...33 Table 4.1: HIV Prevalence by Sample Sites...34 Table 4.2: Relationship between Socio-demographic Characteristics and HIV Infection...34 Table 5.1: Exposure and Knowledge on HIV/AIDS/STI Programs among Male Labor Migrants...36 Table 5.2: Visits to the VCT Centres and clinics by Male Labor Migrants...37 Table 5.3: Participation of Male Labor Migrants in Awareness Raising Program...37 Table 5.4: Interaction of Male Labor Migrants with CHBC Health Workers...38 vi

13 Page Table 6.1: Socio-Demographic Characteristics of Respondents, 2006 and Table 6.2: Male Labor Migrant s Age at First Migration and Duration of Stay in India, 2006 and Table 6.3: Sexual Behavior of Male Labor Migrants, 2006 and Table 6.4: Sexual Encounter of Male Labor Migrants with FSWs in Nepal, 2006 and Table 6.5: Percentage of Male Labor Migrants with Proper Knowledge of HIV/AIDS, 2006 and Table 6.6: Relationship between Socio-Demographic Characteristics and HIV Infection..43 vii

14 LIST OF FIGURES Page Figure 1: Map of Nepal...x Figure 2: Age Distribution of Labor Migrants...10 Figure 3: Duration of Stay of Labor Migrants...12 Figure 4: Age at First Sex of Labor Migrants...15 Figure 5: Main Reasons for not Using Condom with Spouse...18 Figure 6: Main Places of Condom Availability...23 Figure 7: Sources of Knowledge of HIV/AIDS...25 Figure 8: Symptoms Experienced by Labor Migrants in the Current Year...28 Figure 9: Knowledge of HIV/AIDS Transmission...31 Figure 10: Knowledge of HIV Preventive 'ABC' Measures and Comprehensive 'BCDEF' Knowledge on HIV/AIDS...32 Figure 11: Ever Having Sexual Experience with FSW Figure 12: Prevalence of Any STI Symptoms in the Current Year...42 Figure 13: Awareness of Five Indicators of HIV Prevention...43 Figure 14: HIV Prevalence among Labor Migrants...43 viii

15 ABBREVIATIONS AIDS = Acquired Immuno-Deficiency Syndrome DIC = Drop-in Centre FCHVs = Female Community Health Volunteers FSWs = Female Sex Workers GOs = Governmental Organizations HA = Health Assistant HIV = Human Immuno-Deficiency Virus IBBS = Integrated Biological and Behavioral Surveillance Survey ID = Identification Number IDU = Injecting Drug User MSW = Men who Have Sex with Men NCASC = National Centre for AIDS and STD Control NGOs = Non-governmental Organizations OE = Outreach Educators PE = Peer Educators PPS = Probability Proportional to Size SACTS = STD/AIDS Counselling and Training Services STIs = Sexually Transmitted Infections TPHA = Treponema Pallidum Hemaggultination Assay VCT = Voluntary Counseling and Testing VDC = Village Development Committee ix

16 NEPAL Districts covered by IBBS among Male Labor Migrant N CHINA Sample Districts Western Districts: Kaski, Syangja, Palpa, Gulmi and Kapilvastu INDIA Mid-Far Western Districts:, Surkhet, Achham, Doti, Kailali and Kanchanpur x

17 EXECUTIVE SUMMARY This is the second round of the Integrated Biological and Behavioral Surveillance Survey (IBBS) conducted among 360 migrant workers in five districts of the Western development region and another 360 migrants of the Mid to Far Western development regions. The field survey was carried out during the months of June to September The survey measured HIV and STI prevalence among migrant workers, as well as condom use, sexual behaviors, knowledge of HIV/AIDS and exposure to HIV/AIDS messages, cases of sexually transmitted infection (STIs), STI treatment behaviors, and drug habits. Study Methodology Study Population: This cross-sectional IBBS was conducted among male labor migrants of the Western development region and the Mid to Far Western development regions. The recruitment criteria were: A returnee male migrant aged years, having stayed continuously or with interruption for at least 3 months in India as a migrant worker, and having returned to Nepal within three years prior to the date of survey. Sample Design and Sample Size: Two-stage cluster sampling was adopted. In the first stage, 30 clusters were selected using probability proportional to size (PPS). A sample size of 360 labor migrants was deigned for each sector. In the second stage, 12 migrants were selected from each of the clusters selected in the first stage. A list of total returnee migrants available in the selected clusters at the time the survey was updated, and 12 migrants were drawn randomly from this list. A village development committee (VDC) with at least 25 returnee labor migrants in the village was defined as a cluster. Laboratory Testing: Informed oral consent was obtained for HIV testing and the consenttaking process was witnessed by another member of staff. A blood sample was then taken from each respondent. All study participants were provided pre-test counselling for HIV. Blood samples were tested by Determine - HIV 1/2 for detection of HIV antibodies. If the first test result was positive, the second test was performed using Uni-gold HIV 1/2. If there was a tie between the first two tests, a third test was performed using SD Bioline HIV 1/2 as a tie-breaker. Study Findings The labor migrants in the Western region were slightly younger than those from the Mid to Far Western region. The proportion of illiterate migrants was noticeably lower in the Western region (10.6%) than in the Mid to Far Western region (18.6%). Not much difference was observed in the educational attainment of the respondents from the two regions. Nearly all major caste/ethnic groups from both regions were represented in the study. A high percentage of labor migrants from both regions had gone to the state of Maharastra (36.9% in the Western and 34.2% in the Mid to Far Western samples) and to Delhi (43.9% in the Western and 11.1% in the Mid to Far Western samples) for work. A noticeably higher percentage of respondents had also gone to other states in India, including Gujarat, Uttaranchal Pradesh, and Himanchal Pradesh. xi

18 Labor migrants of both regions had migrated at a very young age, mostly while in their teens (67.8% in the Western and 59.7% in the Mid to Far Western samples). Most of the labor migrants stayed with friends (54.2% in the Western and 45.6% in the Mid to Far Western samples) or relatives (28.9% in the Western and 31.4% in the Mid to Far Western samples) while they lived and worked in India. The income of the majority of labor migrants from both regions, irrespective of their place of destination, ranged between NRs. 1 to 5 thousand and NRs. 5 to 10 thousand per month. The great majority of the labor migrants were first married by the age of 24. The great majority in the Western region (86.9%) and nearly all (95. 8%) in the Mid to Far Western region had sex with a female. Most of the respondents had their first sexual encounter by 24 years of age. Within the two regions, the respondents having had sex with a female sex worker in India was higher among those from the Mid to Far Western region. The use of condoms during the last sex act with migrants wives was low (11.3% in the Western and 14.6% in the Mid to Far Western samples). The great majority of respondents (77.4% in the Western and 63.5% in the Mid to Far Western samples) had never used a condom with their wife in the past year. The reason for not using condoms with wives was reported by over half of respondents (55.8% in the Western and 56.4% in the Mid to Far Western samples) as, didn't think it was necessary/didn t think of it. Most of the respondents who last had sex with a FSW in India had used a condom every time (4/5 in the Western and 12/18 in the Mid to Far Western samples). Although sex with girlfriends and other females was also reported, it was not very frequent or common. Nearly all respondents in the Mid to Far Western region (98.6%) and a slightly lower percentage in the Western region (95.8%) had heard about HIV/AIDS. The radio was the main source of information (63.6% in the Western and 72.2% in the Mid to Far Western samples) in both of the study regions. Community networks, especially friends/neighbors/relatives, were another important source of information (57.8% in the Western and 61.4% in the Mid to Far Western samples) on HIV/AIDS. Most respondents were aware of the use of condoms (48.6% in the Western and 68.1% in the Mid to Far Western samples) for protection against HIV. The appearance of any of the STI symptoms in the current year was low (2.5% in the Western and 6.7% in the Mid to Far Western samples) among the respondents. The STI treatmentseeking behavior of the labor migrants was found to be poor. Only about half in the Western region (47.5%) and nearly one-third in the Mid to Far Western region (31.1%) were aware of the availability of confidential HIV testing facilities in the community. A relatively small proportion of respondents in both regions (8.1% in the Western and 11.7% in the Mid to Far Western samples) had ever undergone HIV testing. A relatively small number of respondents in the Western region (7/360) compared to the Mid to Far Western region (54/360) had met, had discussions with, or interacted with peer educators (PE) or outreach educators (OE) in the last 12 months. A small number of respondents in both regions (6/360 in the Western and 15/360 in the Mid to Far Western samples) had visited an STI clinic in the past 12 months. The participation of respondents in HIV/AIDS awareness-raising programs or community events was very low (4/360 in the Western and 19/360 in the Mid to Far Western samples). A smaller proportion of respondents from both regions in 2008 (from 17.2% to 9.7% in the Western region and from 26.9% to 21.7% in the Mid to Far Western region) reported ever xii

19 having had sex with a female sex worker in India than the respondents who had reported on this in The proportion of labor migrants from both regions who had ever had sex with a female sex worker in Nepal had also declined slightly in the 2008 round compared to 2006 results. A small number of respondents had used condoms in the last act of sexual intercourse with a female sex worker in Nepal and in India. Slightly over 60 percent of respondents of both regions had knowledge about abstinence, ( A ), as one of the ways of protecting oneself from HIV infection. About 71 percent knew about being faithful to only one single sex partner ( B ). About 80 percent of respondents knew about the consistent use of condoms ( C ). Knowledge that a healthy-looking person can be infected with HIV ( D ) was 79 percent in the Western and 86 percent in the Mid to Far Western regions. The numbers of respondents knowing that a person cannot get HIV virus from a mosquito bite ( E ) remained low (about one-third) in the 2008 round. Some changes, though not very significant, were observed regarding the knowledge that a person cannot get HIV by sharing a meal with an HIV-infected person ( F ). Knowledge of all three indicators ( ABC ) had slightly declined in the Western region while it had increased in the Mid to Far Western region between the two rounds of the IBBS. Similarly, the knowledge of all five major indicators ( BCDEF ) had remained low (46% in the Western and 48% in the Mid to Far Western samples) in both regions in Out of 360 respondents in both samples, 5 (1.4%) in the Western and 3 (0.8%) in the Mid to Far Western regions tested positive for HIV. In the Mid to Far Western sample of labor migrants, sexual exposure to female sex workers in India was found to have significant association with HIV infection to at least a 5 percent significance level. xiii

20 CHAPTER - I: INTRODUCTION 1.1 Context Nepal is experiencing a concentrated epidemic of HIV with prevalence at, or over, 5 percent in certain high-risk groups, such as intravenous drug users (IDUs) and migrant laborers in India who go to cities such as Mumbai. The possibility of transmission of HIV infection from these high-risk groups to the general population is a serious health concern. Nepal s vulnerability to HIV has increased because of several factors, including poverty coupled with the lack of employment opportunities, large-scale migration, and ten years of conflict. By mid-november 2008, a cumulative total of 12,746 cases of HIV infection had been reported to the National Centre for AIDS and STD Control (NCASC). Among them, 45 percent were clients of FSWs or patients suffering from sexually transmitted infections (STIs); 6.1 percent were FSWs; and 18.3 percent were IDUs. Although the existing HIV/AIDS reporting system at NCASC cannot measure the prevalence rate of the infection because of under-reporting and delays in reporting, this data indicates fairly which subpopulations are affected. In Nepal, socio-economic and political factors are held responsible for inducing large-scale migration abroad, particularly to India. People owning land that cannot support them and those from low economic brackets and who are directly or indirectly influenced by the ongoing political conflict are particularly likely to migrate. A large number of men and women leave their households for seasonal or long-term labor migration to urban centres or to neighbouring countries in search of employment. The migration of laborers is reversible in nature and is characterized by the option for migrants to return to their village of origin at different intervals in the year because they own land (Dilli Ram Dahal, et.al., 1977). Separated from their spouses and adrift from social bindings, many of these migrants exercise unsafe sexual practices. Regular monitoring and health assistance to this population is lacking, especially in the case of those who migrate to neighboring countries like India, compared to those who receive authorized permission to work in other countries. There is no authentic data to indicate the exact linkage between the extent of migration and HIV transmission in Nepal. However, migrants, both internal and external, make up a high-risk group for HIV transmission. Studies conducted among migrant and non-migrant males of Kailali and Achham districts have revealed that international migrants are at a higher risk of contracting STIs and HIV infection (New ERA/SACTS/FHI, 2002). The study found that 7.7 percent of the migrants who went to Mumbai in India from Achham district were HIV positive. Some other studies conducted in the Mid-Far Western hill districts also indicated more than 8 percent HIV prevalence among the migrants who go to Mumbai. In view of such a situation, FHI/Nepal has launched a number of behavioral change and HIV/STI control programs targeted at labor migrants, particularly in the Mid and Far Western districts of Nepal. In this context, New ERA and SACTS with technical support from FHI/USAID, Nepal conducted the first round of IBBS to represent migrants from larger areas in the Western and Mid to Far Western region of Nepal. 1

21 This is the second round of the Integrated Bio-Behavioral Survey (IBBS) conducted in 2008 to collect behavioral data from labor migrants in the Western and the Mid to Far Western districts of Nepal. This round was conducted in order to obtain updated estimates of the prevalence of HIV among the labor migrants, particularly in the age group 18 to 49 years. Apart from the updates on the HIV prevalence, the second round of the IBBS also aimed to assess the changes that have taken place in the migration trends and the sexual behavior of the labor migrants in the Western and Mid to Far Western region since Objective of the Study The overall objective of the study is to determine the prevalence of HIV among returnee male labor migrants from India and to assess their HIV/STI risk-related behaviors. The specific objective of the study was to collect information on socio-demographic characteristics, sexual and drug using behaviors, knowledge of HIV/AIDS, knowledge and treatment of STI problems, and knowledge and the use of condoms from returnee male labor migrants from India in the 11 districts of the Western region and the Mid to Far Western regions and to relate them with HIV infection. 2

22 CHAPTER - II: METHODOLOGY 2.1 Study Population The study population for this cross-sectional Integrated Biological and Behavioral Surveillance Survey (IBBS) was male returnee migrants, who are considered to be one of the high-risk sub-groups. The eligibility criteria were, a male returnee migrant aged years, having stayed continuously or with interruption for at least 3 months in India as a migrant worker and having returned to Nepal within three years prior to the date of the survey. 2.2 Study Area As in the first round of the IBBS, five districts from the Western development region and six districts from the Mid to Far-Western development regions were chosen for this study. These districts were selected on the basis of the concentration of labor migrants who mostly migrate to India. In the selection process, inputs from FHI/Nepal and USAID/Nepal were also obtained. Thus, the Western sample also included Kaski, Palpa, Syangja, Kapilbastu, and Gulmi districts; and the Mid to Far Western sample covered Kailali, Kanchanpur, Doti, Achham, Banke, and Surkhet districts (Fig. 1). 2.3 Sample Design and Sample Size The baseline information on the migrant population and their mobility pattern was already available from the first round of the IBBS. In this study, too, concerned stakeholders at the district and VDC level and local governmental organizations (GOs) as well as nongovernmental organizations (NGOs) representatives were consulted in order to assess the changes that might have taken place on the field situation and the mobility pattern of the migrant population. A rapid listing of the migrants and their status was carried out at the VDC level. Both a maximum and a minimum number of returnee migrants who could be met at the time of the actual field survey was listed in all the study districts gathering information from district headquarter-based GOs and NGOs. Based on the preliminary information collected prior to the field survey, a list of VDCs with an estimated number of returnee migrants from India and those migrants who could potentially be met during the survey was prepared. The average estimated numbers of returnee migrants who would be available in the study districts at the time of the survey was about 19,104 in five districts in the Western districts, and about 37,196 in the six Mid to Far Western districts (Annex - 2). Two separate samples of 360 labor migrants were designed in the Western and Mid-Far Western regions. Two-stage cluster sampling was used to draw the sample. VDCs with at least 25 returnee labor migrants were defined as clusters. In the first stage, 30 clusters were selected using probability proportional to the size (PPS) method; while in the second stage, 12 respondents were selected randomly from each selected cluster. Annex - 3 shows the distribution of selected samples by districts. A total sample of 720 labor migrants with 360 each in the Western and Mid to Far Western region was included in the study. 3

23 2.4 Preparation for Fieldwork Research Instruments A quantitative research approach was adopted. The same questionnaire used in the first round was used in this study as well. However, in order to assess the exposure of migrant workers to HIV/AIDS/STI programs, a series of questions on selected program activities was also collected in this round of the IBBS. Inputs received from the field team during the mock interview sessions conducted at the time the study team was trained were also considered. The questionnaire included questions on demographic characteristics and sexual behaviors: i.e., sexual history, use of condoms, risk perception, awareness of HIV/AIDS/STIs, incidence of STI symptoms, and alcohol/drug using habits (Annex - 4). Apart from the structured questionnaire, questions related to STI symptoms were asked by a health professional to verify the occurrence of such symptoms in the past or during the survey. The study participants were provided syndromic treatment for STI problems and a lab technician collected blood samples for HIV testing. Strict confidentiality was maintained throughout the study period. Study Team The study team included a study director, a research coordinator, a research officer, two research assistants, and field staff. Six field teams were formed for the survey, each consisting of one male team leader/interviewer, four male field supervisors/interviewers, one health assistant, one lab technician and one counselor. Apart from these trained personnel, two locals from each cluster were recruited as a motivator and runner. Locals were involved as team members to obtain their support in building good relations with the community, facilitation in the local language, and to some extent for security reasons. The motivator was more responsible for identifying the individual randomly selected in the sample and for facilitating the recruitment process, while the runner supported the setting up of the clinic and performed other in-house tasks. Both locals hired were given a briefing on the objectives of the survey and their responsibilities as a part of the study team. Recruitment and Training of Research Team Based on past experience and academic qualification, team leaders, supervisors, and counselors were selected for the survey by New ERA. Exposure to HIV/AIDS programs was one of the main criteria in the selection process. For the clinical part of the study, the lab technicians were selected solely by SACTS while health assistants were recruited by New ERA in consultation with SACTS. A one-week intensive training period was organized for all the field researchers focusing on the introduction to the study, administration of the questionnaire (including characteristics of the target groups), methods of approaching them, rapport building techniques, and sharing of previous study experiences (problems and solutions). In addition, the training session also involved mock interviews, role-plays, and class lectures to help researchers understand each question included in the questionnaire. Role-play practice was carried out assuming actual field situations. Possible problems that could be faced while approaching the respondents and ways of overcoming them were discussed. The training also focused on providing a clear 4

24 concept of informed consent, pre-test counseling, and basic knowledge of HIV and STIs to the research team. 2.5 Implementation of the Study New ERA was the prime research organization responsible for carrying out the study and to manage the overall study. The clinical part of the study was conducted in collaboration with STD/AIDS Counselling and Training Services (SACTS). SACTS was responsible for setting up the mobile laboratory in the field sites. It also provided training to the lab technician and the health assistant, and conducted HIV tests from blood samples collected from the study participants. New ERA s overall responsibility was to design research methodology including sample design, to develop the research questionnaire, to recruit and train the field research team, and to carry out data analysis and report writing. Assistance from many local organizations was also sought for the successful completion of the survey. Identification and Recruitment Process The field staff members were briefed about the study areas. District maps with selected VDCs/clusters were also provided to the field team to locate the study areas and plan their work schedule. A meeting at the grass roots level was conducted at each selected site to inform the community about the general objective of the study. Local leaders, health personnel, government representatives, and other key informants were included in the meeting. Updating the List of Labor Migrants in the Selected Clusters Once the study teams were in the selected clusters, they visited each household in the cluster and prepared a list of returnee labor migrants who met the inclusion criteria for the study. Only those migrant laborers who could be met within the study period for that particular cluster were included. For the listing process, information from the key informants, ward visits, or even house-to-house visits were utilized. Five to six days was allotted for each site to update the list, conduct interviews, and provide test results with pre- and post-test counseling. While updating the list, the names of returnee migrants and details of their home address were collected so that the randomly-selected individuals in the sample could be easily traced for interview. Recruitment and Refusal People from local NGOs and community leaders were used as motivators/runners. This helped to build good relations with community people and played a facilitating role in convincing the randomly-selected respondents to participate in the study. Every respondent was briefed on the objective of the study and the benefits and risks of participating in the study. A total of 4 respondents in the Western sample and 31 in the Mid to Far Western sample refused to participate in the study. The primary reason for these refusals was lack of time and no interest in participating in the study. Such refusal cases were replaced by individuals preceding or following in the sampling list. 5

25 Field Work The field work of IBBS among labor migrants in Western and Mid to Far Western regions was carried out during the months of June 29, 2008 to September 15, Field Operation Procedures Clinic Set-up The team used locally available shelters such as health posts, schools, private houses, and even small huts to operate the clinic and conduct interview among respondents. Hygiene was strictly maintained at each set up. There were separate rooms for meeting the respondents, for the laboratory process, for physical examinations, and for conducting interviews. In a few clusters, because of unavailability of rooms, some interviews had to be taken in an open but confidential place. Clinical Procedures Interviews were conducted once informed consent was obtained and the consent form was signed by interviewer and the person who witnessed the consent-taking procedure. After completion of the interview, a trained health assistant (HA) examined the respondent for any signs of STI or general health problems (Annex - 5). All respondents with STI symptoms were provided syndromic treatment according to the national guidelines. Some basic medicines were also provided for the wives of the treated respondents. HAs also made referrals to identified cases that needed additional treatment other than those provided at the clinic. Laboratory Procedures After pre-test counseling, the lab technician briefed the respondents about the HIV testing process and sought consent for drawing blood. Blood samples were drawn in 3 to 5 capillary tubes by finger prick. The samples were tested only for HIV on the spot within an hour. This study was designed to provide test results with pre- and post-counseling in the shortest possible time. Such an arrangement was necessary as the respondents were of a mobile nature and the study team also had to move from cluster to cluster. As a consequence, reagents which can be stored at room temperature were chosen. Blood samples were tested using Determine HIV1/2 (Abbott, Japan Co. Ltd) as first test to detect antibodies against HIV. If the first test result was positive, a second test was performed by using Uni-Gold HIV 1/2 (Trinity Biotech, Dublin, Ireland). In case of a tie between the first two tests, a third test was performed using SD Bioline HIV 1/2 (Standard Diagnostics, Inc., Kyonggii-do South Korea) as a tie breaker. Interpretation of the Test Results All samples negative by first test are reported as negative. All samples positive by one test only subjected to second test. All tests positive by tiebreaker test are reported positive All tests negative by tiebreaker test are reported as negative. 6

26 Quality Control of Laboratory Tests Quality control was strictly maintained throughout the process of the collection of the specimen, handling, and testing stages. All the tests were performed using internal controls. These controls were recorded with all the laboratory data. During the site monitoring visit, a senior lab technician from SACTS performed tests of all positive samples and some negative samples available at the time to ensure quality. All HIV positive samples and 10 percent of the negative samples selected randomly from the total serum collected and stored in filter paper at the sites was tested by different persons at the SACTS laboratory for quality control. The quality control samples were given a separate code number to ensure that the person who performed the quality control had no access to the previous test results. 2.7 Coordination and Monitoring New ERA carried out the overall coordination of the study. SACTS set up the laboratory in the field and undertook the laboratory and clinical part of the study, i.e., collecting, storing, and testing the samples. The principal investigators and research assistants conducted frequent monitoring and supervision of the field activities and coordinated with various concerned organizations to make the study transparent and effective. All the field members were responsible on a day-today basis for ensuring that the study was implemented according to the protocol. Team meetings took place every day to update daily activities and supplies. This helped the team coordinate and solve any field-level problems. To coordinate and operate office-level decisions, field members reported to the senior supervisors or the project coordinator in Kathmandu by telephone whenever necessary. New ERA coordinated with FHI and SACTS to send an appropriate person to the field to deal with any problems reported from the field, as and when necessary. The principal investigators, in conjunction with other designated personnel, were responsible for the overall monitoring. Regular monitoring of the field work also was done from FHI/Nepal. 2.8 Ethical Issues Ethical approval was obtained from the Nepal Health Research Council (NHRC), the Government's ethical clearance body, which approved the protocol, consent forms, and draft questionnaires, and additionally from the Protection of Human Subjects Committee (PHSC) an ethical review board of Family Health International. Informed consent was obtained in a private setting from the selected respondent at the time of recruitment at the field level. The purposes of the study and personal benefits to study participants from the study and the activities to be undertaken were explained in simple terms to all study participants. They were assured of the confidentiality and anonymity of the study procedure. They were briefed on their voluntary participation and freedom of refusal at any stage. Their oral consent to participate in the study was formalized by their signature on a detailed consent form witnessed by an individual from the study team within the clinical setup (Annex - 6). Every respondent were given unique ID numbers as their identification to operate tests and to provide test results with post-tests counselling. They were briefed about use of ID card and how the study team had minimized the risk of losing or mixing with other respondents. This 7

27 also provided additional confidence among the respondents regarding their personal confidentiality. 2.9 HIV/STI Pre- and Post-test Counseling and Follow-Up After the interview using the structured questionnaires, the trained enumerators provided pretest counseling to the participants. Respondents were informed about the process of clinical check-ups and lab tests and the probable consequences of knowing the results and its benefits. These enumerators were well trained on the pre-test counseling process. A rapid test kit was used to test HIV. Participants were asked to wait for an hour or come at a convenient time to get their test result. A professional counselor provided post-test counseling to the participants who came back to receive the results with their ID card after testing (Annex - 7). Both types of respondents with positive or negative test results were given equal importance while providing counseling. More details were provided on subjects relating to HIV/AIDS and STIs. In both steps, respondents were refreshed on the probable social and health consequences and precautions to be undertaken after finding out the results. When dealing with respondents showing positive test results, additional care was given in spite of their informed consent Constraints in the Field Work Frequent transport strikes in different parts of the Western and the Far Western regions caused field researchers delays when traveling from one cluster to another. As the field work coincided with the rainy season it was difficult to find people at home. The researchers had to search for potential respondents on their farms for listing and bring them to the study sites. However, these problems did not affect the quality of the field work Data Processing and Analysis The quality of data was cross-checked at various stages of the study. All the completed questionnaires were thoroughly checked by the supervisors in the field. The consistency of the data was tested by cross examination of the filled questionnaire among different members of the team. These questionnaires were brought to New ERA for further checking, coding, processing, data entry, and analysis. In case of any inconsistency in the data, the respective teams were immediately informed. A double entry system was used to minimize errors in the data entry process. The data entry and data analysis was done by authorized persons on password protected computers only. Simple statistical tools such as mean, median, frequency, percentages, etc. were used to analyze the data. The FoxPro database program was used for data entry and the data was analyzed using the SPSS package. 8

28 CHAPTER - III: KEY FINDINGS This chapter presents the socio-demographic characteristics, sexual behaviors, and condom use patterns of the labor migrants. As in the 2006 IBBS, a total of 720 male labor migrants from 11 districts in the Western and the Mid to Far Western regions (5 districts in Western and 6 districts in Mid to Far Western region) were included in the 2008 IBBS Birth Place and Current Living Place Of the total sampled migrants in the Western region, nearly half (46.7%) were interviewed in Gulmi and about one-quarter (23.3%) were interviewed in Kapilvastu districts. Relatively higher percentages of labor migrants were also interviewed in Palpa (16.7%) and Syangja (10%) districts. The lowest percentages (3.3%) of them were interviewed in Kaski. Similarly, in the Mid to Far Western region, the highest numbers of labor migrants, one-third (33.3%) and another one-quarter (26.7%), were interviewed in Achham and Surkhet districts respectively. A relatively higher number of migrants were also interviewed in Kailali (16.7%) and Doti (10%) districts. About 7 percent were interviewed in both Banke and Kanchanpur districts. All labor migrants interviewed in Kaski were born in the same district. Overall, 95 percent of the responding labor migrants interviewed in the Western region were born in the same district where they were enumerated. In the Mid to Far Western region, the majority of the respondents were also born in the districts in which they were enumerated (Table 3.1). Study Region Table 3.1: Number of Respondent by Birth District 9 No of Migrants Interviewed Migrants Born in the Interviewed District N % Western Gulmi Kapilvastu Palpa Syangja Kaski Total Mid to Far Western Achham Surkhet Kailali Doti Banke Kanchanpur Total Overall, compared to the migrant workers interviewed in the Western region where 95 percent were enumerated in their birth districts, the percentages of migrants interviewed in their birth districts within the Mid to Far Western region (89%) was slightly lower. In this region nearly all the labor migrants interviewed in Achham (98.3%) and Doti (97.2%) districts were born in the same district. Similarly about 92 percent and another 88 percent of the labor migrants interviewed respectively in Banke and Surkhet districts were also born in the same district in which they were enumerated. The lowest percentage of labor migrants

29 (62.5%) born and interviewed in the same district were those in Kanchanpur District (Table 3.1). 3.2 Socio-demographic Characteristics Some differences in the age patterns of the labor migrants was observed between the Western and Mid to Far Western region. The proportion of migrants in the age groups of and years is slightly higher in the Western region while the proportion of migrants in the age groups of and years is higher in the Mid to Far Western region. Nearly one-third of the labor migrants (31.7%) are represented in the age groups in the Western region, while Percent Fig. 2: Age Distribution of Labor Migrants Western Mid-Far Western only about 28 percent are represented in the same age group in the Mid to Far Western region (Fig. 2). Overall, the median age of the respondents in Mid to Far Western region is higher by 1 year (28 years) than in the Western region (27 years) (Table 3.2). Table 3.2: Socio-demographic Characteristics of Respondents Characteristics Western Mid-Far Western N=360 % N=360 % Age Range years years Mean/Median Age / /28.0 Education Illiterate Literate, no schooling Grade Grade SLC and above Ethnic/Caste Group Damai/Sarki/Kami Brahmin Magar Chhetri/Thakuri Terai Caste Musalman Tharu Kumhal Sanyasi Newar Kurmi Gurung Rai Others (Dhobi, Sunwar, Sundi, Rajbhar, Gaderi/Pal, Tamang) Marital Status Married Divorced/separated Widow Never married Currently Living With With wife With parents Others (with children, relatives, alone) No response